COMPROBACIÓN DE HIPÓTESIS (DISCUSIÓN)

This investigation examined the processes nursing students use to resolve a healthcare situation. More specifically, the processes of critical thinking and clinical judgment were evaluated. Also included in this study was whether grand rounds as an educational strategy enhanced the development of critical thinking and clinical judgment in nursing students. The research questions developed for this study were:

1. How do nursing students use critical thinking skills and clinical judgment to resolve a healthcare dilemma?

2. Does grand rounds as an educational strategy promote development of critical thinking and clinical judgment in nursing students?

In this chapter, the investigation sample is described followed by the findings for each research question.

Participants in the intervention groups completed a semi-structured interview (Appendix E) which provided the data to answer these questions. Interviews were assessed qualitatively through content analysis by identifying patterns, themes, and processes (Merriam, 2009). After the interviews were transcribed, recurring patterns were noted in the margin of the transcript, and sorted into categories. Once recurring patterns were noted, themes or processes were developed that captured the interview content. Clinical judgment data were analyzed using content analysis by the

researcher and the Simulation Lab Coordinator using Lasater‘s Clinical Judgment Rubric (2007b). Participant scores‘ on the Assessment Technologies Institute Critical Thinking Assessment were evaluated with paired t-tests (Polit & Beck,

2004). Spearman‘s rho was used to analyze the relationship between clinical judgment and critical thinking (Polit & Beck). Participants‘ scores on the Lasater Clinical Judgment Rubric were assessed with independent t-tests. The data were analyzed with the Statistical Package for the Social Sciences (SPSS), version 16.0.

Sample Characteristics

Following a brief presentation of the study, 22 Level II nursing students volunteered to participate in the investigation. Of the volunteers, 19 of the participants were female and three were male. Since the sample size was small, caution should be used to evaluate and interpret the results. Students‘ ages ranged from 19 years to 50 years (M = 27), for the intervention groups and 20 years to 33 years (M = 24.5) for the comparison group. Students‘ grade point average (GPA) ranged from 2.50 to 4.00 on a 4.00 scale for the intervention groups and 2.75 to 3.75 for the comparison group.

Findings

Research Question One

The first question stated: How do nursing students use critical thinking skills and clinical judgment to resolve a healthcare dilemma? Participant interviews regarding their thoughts on critical thinking, clinical judgment, and teaching

strategies to promote development of those skills were used to answer this question. Also, participant responses in resolving the healthcare dilemma as assessed with the Lasater Clinical Judgment Rubric were assessed with content analysis to determine how the participants resolved the dilemma. Included here is an explanation of the

concept or concepts identified through content analysis followed by excerpts from the participant interviews that support the identified concept.

Participants identified critical thinking as including the habits of mind that direct the individual to think in a different way when faced with a difficult situation. Habits of mind included logical reasoning, deductive reasoning, thinking outside the box, looking at the problem from different angles, and abstract thinking.

Able to come up with a solution or deductive reasoning, thinking outside the box, it‘s not black and white, it‘s not clear cut. You have these symptoms, it could be this, this, or this. A little more research and you‘re able to narrow down and logically come up with a solution. (Drew)

You have to look at every situation and look at, like one situation there could be hundreds of possibilities. Your job is to narrow it down, and by using critical thinking, you can narrow it down hopefully to the right treatment, diagnosis, whatever. (Skylar)

When you‘re able to look at something in an abstract way, from all different angles of a problem and you‘re able to solve it by, I don‘t know, sometimes you think outside box or take a lot of things into consideration and coming up with a solution to a problem, you don‘t really think along a line, try and see something from all different angles. (Dallas)

Looking at a situation from multiple, different vantage points and then coming to the best idea or answer that you feel you have by taking in everything that you can, all the information. (Tyler)

Using all of, like looking all of the dimensions of it and then pulling from it different ways to, kind of problem solving, to come up with an answer. But not just using concrete thinking, using abstract thinking. (Stacy)

Being able to think of things from different angles; being able to think outside the box, to think of things in different ways, maybe just than what it appears to be. (Alex)

Being able to think outside the box. Making sure that you can put all the pieces of the puzzle together and connecting the dots, but mostly thinking outside the box. How the person presents may not be what‘s going on. So

you have to be able to connect all the dots and focus in on what‘s important, from their symptoms and stuff. (Jess)

Critical thinking is based in previous life experiences. This includes knowledge gained from the classroom as well as outside activities. Students‘ experience can be gained in the clinical setting, in simulation, or through work. Many nursing students work in a healthcare environment, but others also work in other service industries.

Critical thinking, to me, is taking the knowledge you‘ve amassed, in school or from life experiences, and having a problem set in front of you, and then applying that knowledge to that problem. (Chris)

Being able to think on your feet. Being able to apply the book work we learn in class and make it work for the individual situations that you‘re put in. Be able to make sound decisions and trust what you‘re going to do it the right thing to do. (Ellis)

You would make an educated decision, not just a fly-by-the-seat-of-your pants decision. Hopefully you would be able to think about it and come up with a correct decision based on your experiences and learning. (Taylor) The ability to have the knowledge and apply it when it‘s necessary in the situations you come to. (Sydney)

Critical thinking also means identifying relevant information, examining it within the context of the patient and their condition as well as expected findings, and

determining a correct course of action.

Not everything is clear and finite in nursing, you have to kind of look at a lot of the parameters of what your patient has going on, so this leads to that. It‘s almost like how we do concept maps. Like you just have to kind of follow what‘s going on and analyze your patient and then think, ok if this happens then this happens. You almost have to be one step ahead of yourself so that you can anticipate what‘s coming next. (Pat)

Being able to differentiate between information relevant to a situation and information that‘s not relevant and figuring out what‘s the most important to a particular moment or situation and applying it. (Robin)

Probably being able to take a bit of information and analyze it, in all different aspects, to think of different scenarios, about what could happen. Like, if you‘re given this patient and they get this kind of medication, like, anticipating what could happen, you know, different things. (Terry) When our patient is in a situation then it‘s not always going to be a direct answer. Every situation‘s different. Every patient‘s different. You just have to think, how am I going to treat this patient versus how you would treat a different patient. (Alex)

Critical thinking allows for identifying relevant information and clinical judgment is then that decision that is made and how the course of action to be taken to handle the situation. A practitioner needs to possess good critical thinking skills to identify the needs of a patient so an appropriate course of action can be initiated.

The way I see clinical judgment is kind of like seeing the problems in the clinical setting and then making a diagnosis, if you will, of that problem. And then on top of that, judging what to do. I guess just figuring out what to do whenever you‘re faced with a problem; making a choice, a decision on the best approach to take to the situation. (Chris)

Assessing the situation and then using your knowledge and previous experience to determine what you need to do. (Jamie)

Being able to make good decisions based on the circumstances in a situation. You have to have good insight into what to do, how to prioritize things. (Dallas)

Being able to make decisions based on knowledge that you already have and being able to make the right judgment based on that. (Terry)

Based on the information given, making a choice regarding the best choice or treatment for the patient. (Drew)

I think you‘d maybe use critical thinking to put together your judgment but I think you do critical thinking without the judgment portion of it. (Tyler) Based off assessments and stuff, figuring out what‘s going on. (Stacy)

Every sign and symptom you have with a patient, you have to determine if this is a critical thing, if this is something that‘s going to go away in five minutes and then I don‘t have to worry about it or is it something that could kill them in ten minutes if I don‘t pay attention to it. (Robin)

I think they‘d have to have critical thinking to have a clinical judgment because if you don‘t know how to change and adapt to the situation then your clinical judgment is just going to be the standard that you were taught in school but don‘t know how to apply it. (Ellis)

When you‘re in practice, using good judgment as far as working within an ethical sort of boundary and proper protocols, you know, like hospital regulations. (Jess)

For some students, critical thinking and clinical judgment are inter-related and difficult to distinguish from each other. Both skills relate to patient care, identifying needs, and developing a plan of care.

Clinical judgment, I think, they parallel each other but they might not be the exact same thing. They overlap in certain areas but I think they differ just slightly in the way that you think. (Pat)

Kind of the same thing as critical thinking, making the right decisions. Your judgment is based on how you think about each situation, so hopefully if you‘re a good critical thinker, you‘ll get to the right point. (Skylar) It would be a lot like critical thinking. It‘s just more in a clinical setting. Sometimes in different situations, things that might be really important may not be very important in another situation and something else if it‘s an emergency situation. So you just have to use your better judgment to determine if that‘s really the most important issue at the time or if it‘s something else that‘s more important. So if you can‘t think critically, then your judgment‘s going to be completely off. You don‘t have a clue. Conversely, if you‘re a good critical thinker and think through every

situation, then when you get in that clinical situation, you‘ll be able to better pinpoint that issue‘s that‘s pressing. (Robin)

You have to have good critical thinking to make good precise and accurate clinical judgment. (Terry)

Participants in the intervention groups were more likely to discuss openly the concerns they identified in the healthcare dilemma. They accessed resources more often such as their iPod to assess laboratory values or a medical-surgical textbook to better understand the disease process and what to anticipate. Participants in the intervention groups worked as a group to address the healthcare problems by frequently dividing the tasks in accessing information. This was done as a group process without one person taking responsibility or delegating tasks. Through open dialogue and discussion, participants in the intervention groups would problem-solve bringing into play material learned in class or through experience. Participants would often develop a course of action together before advancing to the next patient state.

This group processing stimulated thinking in other members of the group. Often, it seemed as if what one participant said enabled another participant to recall material from class or their clinical experience that could help clarify or provide more questions to resolve the healthcare dilemma. This helped all group members recognize that they were all part of the team and that it was not just one student in class answering a question. Group processing of the healthcare dilemma also provided an example to participants with lower clinical judgment ability of the type of thinking that is involved or the questions to ask and the information to seek.

Participants in the intervention groups achieved higher scores on the Clinical Judgment Rubric than the comparison group. In the intervention group 33% of the responses were at the beginning level compared to 77% for the comparison group.

Clinical Judgment scores‘ percentages at the developing level were higher for the intervention groups, 38%, than the comparison group, 16%. The comparison group had no responses that could be categorized as accomplished or exemplary. This contrasts with the intervention groups who had 24% responses at the accomplished level and 5% of the responses at the exemplary level.

A variety of teaching strategies are used at the nursing school that these students attend. Concept maps enable students to realize the connectedness of factors in patient care and to anticipate problems. The concept maps require quite a bit of time for students to construct them. So, even though participants sometimes view the concept maps as time consuming, they eventually came to realize the benefit of completing them.

At first I thought it was more busy work but as I started doing it, it really does help you to think, not really putting it together but when you‘re connecting all the lines, it really does get you to think then. (Pat)

It does tie everything together. You know you have to have this leading to this. It helps you think of all those things. (Terry)

On top of that, I think the concept mapping helps out a lot as well because it maps out potential complications and then you have to put in interventions and what you might do in the event that something does happen. (Chris) Once I get it done, I see it, but pulling it all together, I can see it with the lines and rationales. (Robin)

I really do, especially just for figuring out how it all fits together. You can see how it all fits together. You know, what was wrong with your patient, what was going on, how they‘re all related. (Dallas)

They gave me a possible cause and effect, show linkages between things which could be helpful. (Drew)

Yes, you look at your patient from different angles, like what ties to which thing, and how they all relate. (Stacy)

I could identify what the nursing diagnoses are the problem and then in terms of the interventions and the meds and stuff, it all just kind of flows together. At the end then you‘ve got all of the potential complications or things that could impact the patient. (Kelly)

They helped you see how things can cause other things and how they all tie together. (Alex)

I think that they help you connect different areas to other areas; that pain can relate to something else, that risk for infection can relate to pain. They‘re all intertwined in certain ways. (Jess)

A few students did not feel the concept maps were helpful for developing critical thinking and clinical judgment. This may be reflective of learning style. Some students felt the benefits of concept maps did not continue into the second Level of nursing school.

I don‘t think concept maps helped that much, unless you were just breaking it down to see why you had this nursing diagnosis. (Bailey)

Concept maps helped with labs, but as far as interventions, never really, I guess I just got it and concept maps were just a waste of time. (Jamie) I‘m not tired of them, it just doesn‘t really help me that much. Sometimes you anticipate certain things but you can‘t put a specific name to them but then when you do a concept map you have to have a specific thing. Like the interventions you write down are pretty usually common sense type of things, like not even thinking. They help maybe the first semester but I don‘t think they‘ve helped this semester that we‘ve done. (Tyler)

Many students did not feel that case studies were beneficial. Reasons cited for this were it did not fit with their learning style, too specific, or were too brief. Nursing students also feel pressed for time with all the demands of their classes. So, if this learning activity was optional, it tended to not be completed.

Those helped out a bit but it was kind of hard because they were so fast- paced that it was hard to really focus on it and then there was so much other stuff going on, you know. (Chris)

Just because it basically was outlining what we learned in class already, like the signs and symptoms, so a lot of case studies were just straight out like, ok this person has this signs and symptoms, this, this, and this, and I had already learned that. So to me it didn‘t really help too much. (Tyler)

I think there‘s just so much in nursing school, you just want to get the bases of stuff. It feels like we just have enough time to learn the material and all those other things probably would help but we don‘t have time for it. When we actually sit down and do that stuff it helps. (Skylar)

Sometimes [helpful]. I don‘t do a lot of them because I‘m not a writer so I‘d much rather discuss it than have to write it down and turn it in. I don‘t do as well with writing. (Ellis)

Participants who thought case studies were beneficial related that it provided an opportunity to apply information learned in class. Students who felt they were helpful typically limited their benefits. Case studies were not as valuable as other learning strategies.

Yea, I think for me, most case studies required research. You know if I had a case study, I‘d go back and try and come up with something, read about symptoms or come up with a best course of action on research. It usually wasn‘t cut and dried, you‘d have to use some of that deductive reasoning based on what the question was. (Drew)

You kind of go through the motions without the patient involved. It can give you more difficult situations than you do in clinical, more than what you‘d feel comfortable with, and do stuff and learn. (Alex)

Those were helpful just because you could read it all out. It‘s harder for me